Embed Size (px)
Citation preview
Board of Directors Meeting
Open Session
Tuesday January 29, 2019
Boardroom, Level 2 Administration
115 Delhi Street
Guelph, ON, N1E 4J4
Dinner available in the Boardroom starting at 5:30 p.m.
MISSION: To provide the highest quality care and experience for patientsand their families
a) Summary of Motions
1 min 3. Chair Remarks Information D. Mills
a) Approval of Agenda - January 29, 2019
b) Approval of Minutes - November 27, 2018
19-01-29 CEO Report - Page 10
c) President and CEO Report
19-01-29 COS Report - Page 19
MAC Highlights - Dec 2018 - Page 20
d) Chief of Staff Report
19-01-29 Agenda - Page 4
18-11-27 Minutes - DRAFT - Page 8
EMAHS Newsletter - Nov 2018 - Page 13
1 min 5. Approval of Agenda and Consent Agenda Decision D. Mills
1 min 1. Welcome and Call to Order Information D. Mills
1 min 2. Declaration of Conflict of Interest Information D. Mills
19-01-29 Summary of Motions - Page 3
30 min 4. Departmental Tours - Information Technology andStroke Program
Information D. Maw/J.Garrity
MAC Highlights - Jan 2019 - Page 21
1 min 6. Next Meeting - February 26, 2019 Information D. Mills
1 min 7. Meeting Adjournment Decision D. Mills
19-01-29 OPEN BOD Package19-01-29 OPEN BOD Package
AGENDAAGENDA
Page 2 of 21
BOARD OF DIRECTORS JANUARY 29, 2019
SUMMARY OF RECOMMENDED MOTIONS OPEN SESSION: Agenda and Consent
a) Approval of Agenda – January 29, 2019 b) Approval of Minutes – November 27, 2018 c) President and CEO Report d) Chief of Staff Report
It is recommended that the Board of Directors approve the Agenda and Consent Agenda as presented. Open Session Adjournment
Page 3 of 21
AGENDA – OPEN MEETING Board of Directors
Tuesday January 29, 2019 6:00 p.m.
Boardroom, Level 2
AGENDA ITEM LEAD ACTION TIME
1. Welcome and Call to Order D. Mills 1 min
2. Declaration of Conflict of Interest D. Mills Information 1 min
3. Chair’s Remarks
a) Summary of Motions
D. Mills Information 1 min
4. Departmental Tours – Information
Technology and Stroke Program
D. Maw/J. Garrity
Tours 30 min
5. Approval of Agenda and Consent Agenda: a) Approval of Agenda – January 29,
2019 b) Approval of Minutes – November
27, 2018 c) President and CEO Report d) Chief of Staff Report
D. Mills
Decision 1 min
6. Next Meeting:
February 26, 2019
D. Mills Information
7. Meeting Adjournment D. Mills Decision
Page 4 of 21
GUELPH GENERAL HOSPITAL - BOARD OF DIRECTORS COMMITTEE MEMBERSHIP 2018-2019
Administration & Facilities Committee David Kennedy - Chair Dr. Steven Hoey* Rod Carroll – Resource Cheryl Cowden – Resource Fraser Edward David Forestell VP Patient Services Dale Mills Marianne Walker Glen Weppler – Community Member Gavin Webb – Resource Mark Zonneveld – Community Member
Audit Committee David Kennedy - Chair Christine Bevan-Stewart David Forestell Cheryl Cowden – Resource Dale Mills Brad Riley – Community Member Marianne Walker (non-voting) Gavin Webb - Resource
Nominating Committee Dale Mills– Chair Brian Cowan Marianne Walker Kathy Wilkie
Governance Committee Ted Sehl - Chair Rena Hubers Brian Cowan Janet Kaufman Dr. Ian Phillips* Dale Mills Marianne Walker
Quality Committee Kathy Wilkie – Chair Christine Bevan-Stewart Jennifer Caspers Jodi Coleman – Community Member Terry Campbell VP Patient Services Dale Mills Sarah Sayyed Melissa Skinner Matt Stanley Marianne Walker Karen Suk-Patrick Lise Betteridge – Community Member
IT Advisory Committee Dale Mills – Chair Jennifer Caspers Dan Coghan (North Wellington) Fraser Edward VP Patient Services Dale Maw – Resource Brian McMahon – (North Wellington) Community Member Stephanie Pearsall (Groves) Anca Preda – Community Member Stephen Street – Ex-Officio Paul Smith – (Groves) Community Member Gilles Madore – (Groves) Community Member Marianne Walker – Ex-Officio Gavin Webb
Page 5 of 21
BOARD OF DIRECTORS MEETING ATTENDANCE
2018-2019
Sept 25
Oct 30
Nov 27
Dec 10 Retreat
Jan 29
Feb 26
Mar 26
Apr 30
May 28
June 25
AGM
Dale Mills - Chair P P
Eileen Bain P P
Christine Bevan-Stewart P P
Terry Campbell P P
Jennifer Caspers P P
Brian Cowan P R
Edward Fraser P P
David Forestell P P
Steven Hoey – President MSA P R
Rena Hubers P R
Janet Kaufman P R
David Kennedy P P
Sara Sayyed P P
Edward Sehl P P
Matt Stanley P P
Marianne Walker P P
Kathy Wilkie – Vice Chair P P
GUESTS:
Ian Phillips – VP MSA R R
Suzanne Bone P P
Rod Carroll R R
Gavin Webb R P
Amanda Babensee - Recorder R P
Page 6 of 21
BOARD OF DIRECTORS
OPEN SESSION MOTION SUMMARY 2018-2019
MEETING DATE MOTION ACTION
REQUIRED/UPDATE
Page 7 of 21
MINUTES – OPEN MEETING - DRAFT Board of Directors
Tuesday November 27, 2018 Boardroom, Level 2
Present: D. Mills – Chair, E. Bain, T. Campbell, J. Caspers, B. Cowan, F. Edward, D.
Forestell, S. Hoey, R. Hubers, J. Kaufman, D. Kennedy, T. Sehl, M. Stanley, M. Walker, K. Wilkie and A. Babensee - Recorder
Regrets: C. Bevan-Stewart Guests: G. Webb, S. Bone
1. CALL TO ORDER
The meeting was called to order at 6:00 p.m. 2. DECLARATION OF CONFLICT OF INTEREST
No conflicts of interest were declared.
3. CHAIRS REMARKS
D. Mills referenced the Summary of Motions included in the package. a) Summary of Motions
4. APPROVAL OF THE AGENDA AND CONSENT AGENDA
a) Approval of Agenda – November 27, 2018 b) Approval of Minutes – October 30, 2018 c) Governance Committee Report d) Audit Committee Report e) President and CEO Report f) Chief of Staff Report
It was MOVED by D. Kennedy, SECONDED by B. Cowan that the Agenda and Consent Agenda as presented. CARRIED.
Page 8 of 21
5. NEXT MEETING
The next meeting – Board of Directors Retreat – December 10, 2018
6. ADJOURNMENT It was MOVED by T. Sehl to adjourn the meeting at 6:10 p.m. ______________________________ ________________________________ Chair – D. Mills Secretary – M. Walker
Page 9 of 21
REPORT OF THE PRESIDENT AND CEO BOARD OF DIRECTORS OPEN MEETING
January 29, 2019
Provide the safest and highest quality care Trillium Gift of Life I’m proud to report in the past year GGH had the highest number of organ donors of all WWLHIN hospitals. In fact, we were also among the highest of large community hospitals in the province. Through collaboration with The Gift
of Life Network and early identification of potential organ donors we had a profound impact on many lives.
So much credit goes to our exceptional team in our Intensive Care Unit. They have been the driver behind our organ donation success. The skilled ability of our physicians, nurses and Respiratory Therapists to care for patients who are donating organs increases the likelihood of a successful implantation. We are proud of our team and extend our congratulations to them.
Medication Safety Our team continues to work on improving medication safety through improved processes and automation. The team identified that to complete a closed loop medication delivery system, Computerized Order Entry was required. Several physicians and staff visited a site where they had fully automated medication delivery including bar coding. A closed loop medication system will require significant change management and we are working through the details of the implementation plan. Engaging Patient and Families Our Patient and Family Advisory Council has been actively becoming more familiar with the organization over the last few months. There has been a mix of presentations from staff wanting feedback or input from the Council. Some of the initiatives that the Council has been involved in include: feedback into the Patient Declaration of Values, pediatric pain management strategies, infection control, falls prevention, Quality Improvement Plan and surgical tracker. Finally, one of our Council members recently participated in the interviews for our Vice President /Chief Nursing Executive position. This was a very positive experience for all involved. We are very thankful and privileged to be working with such dedication and committed volunteers.
Page 10 of 21
Emergency Mental Health and Addiction Services (EMHAS) Report The Steering Committee and Work Groups continue to make progress in providing the needed emergency mental health and addiction services. I have attached our latest newsletter for your information.
Support our Exceptional Staff
Healthy Hospital Survey Results
Our Healthy Hospital results are in and once again our engagement scores are high and improvements are noted. Compared to 20 other hospitals, our
engagement score for staff was 71% vs the average of 68.4% and for Professional staff the engagement score was 75.1% versus the average of 69.3%. Each department now has their departmental scores and will develop a plan for improvement. We are committed to continue to work with our staff and professional staff to continue to make
GGH one of the best places to work.
Create a coordinated high quality system of care with our partners. Sub-Region Planning Our Sub region partners continue our work on how we could work together in the future to improve the health of our community. Our areas of focus are palliative care, mental health and addictions and chronic disease. A plan for our Collaborative Quality Improvement Plan will once again focus on
improving outcomes for people who experience Heart Failure. We are also building on our work from the Board Retreat to explore if we get agreement on the vision for health care in our sub Region. I participated on a Mayor Task group to end homelessness. This is a diverse group who are committed to improving the lives of the most vulnerable people who living in our community. A report will be circulated and a plan will be developed.
Sustain our Financial Health
Managing Over Capacity and Operational Pressures at GGH We continue to experience growth in inpatient activity compared to prior years. Overall our patient days increased 5% compared to December 2017 and are 15% higher than December 2016. For perspective, this means we have an average of 24 more patients in hospital each day than we did 2 years ago and
9 more patients than we did last year. This demonstrates two years of high growth in patient days.
Page 11 of 21
This increase in patient days is largely driven by higher admissions from the Emergency Department and an increase in Alternate Level of Care (ALC) patients waiting for the correct placement to become available in the community.
• The ED admission rate increased 4% compared to December 2017 and 13% over December 2016. This accounts for approximately 68% of our increased patient activity. • ALC patient days have increased by 17% compared to December 2017, with an increase of 4 additional beds per day. Year-to-date December 2017 we had an average of 23 patients per day and this year the average is 27 patients per day.
The above pressures result in an overall increase in Medical bed occupancy from 107% in December 2017 to 114% in December 2018. To accommodate these patients, we kept open the 12 beds opened for the 2017/18 flu season, and in July we opened an additional 4 beds. We received one-time funding to operate 5 of the 17 total additional beds. Therefore, 12 of the beds are considered unfunded and is the primary cause of our unfavourable year-to-date variance. These pressures have put a financial strain on balancing our budget and we continue to experience a deficit.
40,000
42,000
44,000
46,000
48,000
50,000
52,000
16 /17 Dec YTD 17 /18 Dec YTD 18 /19 Dec YTD
Total Patient Days
Page 12 of 21
EMERGENCY MENTAL HEALTH AND ADDICTION SERVICES (EMHAS) Fall/Winter2018 Edition
SERVICE DEMANDS CONTINUE TO GROW
Groves Memorial Community Hospital, Palmerston Distict Hospital and Louise Marshall Hospital Mental Health ED Visit Volumes
Substance Abuse ED Visit Volumes
Guelph General Hospital
Mental Health ED Visit Volumes
Substance Abuse ED Visit Volumes
From the start, EMHAS services have experienced a growing demand. Guelph and the surrounding area is recognized as one of the fastest growing census areas in Canada. At Guelph General Hospital’s Emergency Department, there has been a 37% growth in mental health related visits and 40% growth in substance abuse related visits for adults over the past five years. Groves Memorial Community Hospital, Palmerston District Hospital and Louise Marshall Hospital have also seen steady percentage growth in the number of adult patient visits: 39%, 25% and 8% respectively for mental health and 26% and 81% (combined for PDH and LMH) for substance abuse.
Page 13 of 21
The Short Stay Assessment Unit (SSAU) continues to function within the Guelph General Hospital Emergency Department providing specialized psychiatric care for adult patients awaiting disposition. Following a period of observation and assessment, the SSAU facilitates admission, if necessary, to Homewood Health Centre or provides resources for outpatient support upon discharge. The SSAU team embraces the Emergency Mental Health and Addiction Services (EMHAS) vision of creating a safe environment for the provision of integrated and dignified emergency care for patients with mental health and substance use related conditions.
Some quick stats – in the last year:
620 adult patients were transferred to the SSAU which is a 24% increase over the previous year
The average length of stay in SSAU is 33.9 hours and 65% of patients that were transferred to the SSAU were discharged to home following
a short period of stabilization
SHORT STAY ASSESSMENT UNIT
IMPROVING COMMUNICATION WITH OUR PATIENTS AND FAMILIES: WHAT DOES A FORM 1 MEAN TO ME?
EMHAS continues to improve interactions with patients so that they may experience the best care possible when they visit our Emergency Departments. Recently, a point of confusion was identified as to what information patients were given when they were being placed on a Form 1. In some instances, patients received copies of the Form 1 and Form 42, that were filed on their patient record in the Emergency Department.
EMHAS has developed a new handout, called What Does Form 1 Mean to Me, to be given out to patients who will be transferred from the Emergency Department they have visited to a Schedule 1 program (e.g., Homewood). We have sought feedback on the information sheet from our patients and the tool has already been launched at North Wellington Health Care and Groves Memorial Community Hospitals.
The handout is in the final approval stages at Guelph General Hospital, and we hope that the tool will be available at GGH in early 2019.
Fast Facts About Form 1 The Ontario Mental Health Act gives every
physician in Ontario to right to sign an Application for Psychiatric Assessment, also known as APA or Form 1
Following a thorough clinical assessment, the physician may decide to hold a patient for in-depth psychiatric assessment, and then completes the Form 1
The Form 1 is filed on the patient’s record. The patient is informed of the Form 1 decision.
Fast Facts About Form 42 Under the Mental Health Act, a patient is to be
given a Form 42 when they arrive at a Schedule 1 program.
The Form 42 explains to the patients why they have been placed under the Form 1.
This form also states a patient may be kept in that hospital for up to 72 hours so that an in-depth psychiatric assessment is completed.
Page 14 of 21
As part of the continuous efforts to learn and share knowledge, the EMHAS Team has provided quarterly Lunch and Learn sessions. The EMHAS Lunch and Learn sessions are great way to network and are offered in person to all staff within EMHAS and GGH. Sessions are also made available on OTN for our rural hospital sites to join. Topics recently presented:
A Life Cut Short - A Review & Recommendations from the Chief Coroner’s Office by Dr. Brian Furlong The Nature of Nurture: Neurodevelopmental Risk Factors for Adolescent Substance Use by Tony Renda
Some sessions are specifically offered to Emergency Department staff at staff meetings. The November 16/18 session was also made available to the rural hospital sites via OTN. This session covered:
Borderline Personality Disorder and the Emergency Department by Tara Endeman This session is being archived by OTN for later viewing.
A major goal of the EMHAS team is a focus on continuous process improvement. Team efforts have resulted in a continued reduction in turnaround times over a four-year period. The “Race to the Patient” philosophy is working well! Since the project started, we have seen a 29% improvement in our 90th percentile ED LOS for patients with mental health and addictions related ED visits at Groves and a 25% improvement at GGH. Palmerston and Louise Marshall have continued to meet or exceed the target!
EMERGENCY MENTAL HEALTH AND ADDICTION SERVICES (EMHAS) EDUCATION SESSIONS
EMHAS QUICK STATS
2014/15 YE 2015/16 YE 2016/17 YE 2017/18 YE
GGH 16.9 13.1 13.1 12.7
Groves 21.1 11.9 13.7 14.9
PDH 6.5 6.2 6.1 6.1
LMH 6 4.5 7.2 8.1
Target 10 10 10 10
0
5
10
15
20
25
Ho
urs
90th percentile ED LOS for adult patients with mental health and addictions visits
Page 15 of 21
Emergency Mental Health and Addiction Services in Rural Wellington continue to provide vital emergency support to local residents. Earlier this year, the Emergency Mental Health and Addictions Services Rural Working Group completed a future state value stream map to identify operational needs to support implementation of rural hospital medical psychiatry services. The process map showed that nursing assessments need to be completed prior to psychiatric assessment as patients often have concurrent medical and psychiatric needs. Based on these findings, the timing was right to consider changing the way this service is delivered as partners’ capacities and mandates have evolved since the service started.
New Model Development With the goal of providing patients with the best care, the Rural Working Group partners explored the issue and developed a focused model of care with clear alignment of roles and responsibilities. The decision made will see the Canadian Mental Health Association Waterloo Wellington assume responsibility for emergent assessments for pediatric mental health patients and community mental health services and Homewood Health Care (HHC) will deliver services to adults (aged 18 and older) in the acute care hospitals.
Revised Staffing Model Patient presentation data were reviewed to inform the new service model. We learned that:
The majority of mental health and addictions presentations take place between 08:00 and 24:00 hours. Visit volumes are fairly steady throughout the week, demonstrating the need for a 7 days per week service. Scheduling of staff between 0800 and 2400 would align with presentation of 90% of patients and would also
provide sufficient time for nursing staff to travel between rural hospital sites.
The new model has a HHC registered nurse assessing patients 18 years and older (including geriatric patients) who will be exclusively dedicated to the rural hospital settings 7 days per week between 0800 and 2400. The key advantages of this model are:
Reduced duplication of mental health and addictions assessments, Alignment of staffing to the hours when most patients come to the emergency departments, and An ability to provide timely support when a rural psychiatrist joins the team.
EMHAS RURAL IMPROVEMENTS
RURAL ADDICTIONS COUNSELLING PILOT PROJECT
The EMHAS Team was enhanced at Groves Memorial Community Hospital, Palmerston District Hospital and Louise Marshall Hospital with an Addictions Counsellor in the past year, as a pilot project temporarily funded by the Waterloo Wellington Local Health Integration Network (WWLHIN). The counsellor has been available to the hospitals to provide assessments for patients experiencing addictions issues. With the increasing volumes of addictions patients in our local Emergency Departments, this new capacity has greatly enhanced the delivery of effective and timely care and support to adult patients. Consultations with the WWLHIN are in process related to ongoing funding for these positions.
Page 16 of 21
The Mental Health Addictions Emergency Follow-up Service (MHAEFUS) has marked its first anniversary of operation with a resounding success. Adult patients are referred to this concurrent service either from the Emergency Department or the Short Stay Assessment Unit to obtain support. This service is staffed by an Occupational Therapist, Social Worker, and Addictions Counsellor. Support may be offered in three ways – one on one, by telephone, and/or therapeutic groups.
The purpose of these groups is to provide concurrent support for those individuals who have been discharged back to the community, and who would benefit from immediate support due to the acuity of their mental health needs. The groups also provide in-patient programming for individuals who have been admitted to the Short Stay Assessment Unit. Overall these follow-up services provide short term support, and bridge any gaps that may exist for accessing other community services once a patient has been discharged from hospital. The program goal is to decrease the risk of repeat Emergency Department visits.
The focus of the groups is on practical coping skills applicable to urgent care needs, including distress tolerance, emotional regulation, safety/ crisis management, mindfulness and supporting stability of function. A group format allows for learning skills in a social and supportive environment with peers.
Key Highlights of MHAEFUS’ First Year
October 2017 – September 2018
366 group therapy sessions were held 811 people attended a group session 1332 people had individualized appointments with a
clinician 264 people received telephone support 30-day repeat ED presentations were reduced by half for
those attending MHAEFUS programs Almost 60% of patients that attended MHAEFUS reported
having a concern related to substance use 46% of individual appointments and 21% of our group
sessions were specifically related to substance use
MENTAL HEALTH AND ADDICTIONS EMERGENCY FOLLOW-UP SERVICE
MEDICAL PSYCHIATRY SERVICE AT GUELPH GENERAL HOSPITAL
The EMHAS Team expanded this fall, welcoming Tara Endeman as the Clinical Nurse Specialist for the Medical Psychiatry Service (formerly called the Consult Liaison Service) at Guelph General Hospital. This is a new role within the team that provides consultation and support to inpatient medical and surgical programs for patients experiencing mental health and/or addictions issues in addition to a medical condition. In a very short period of time, the program has proven helpful:
From September 1 to November 30, there were 87 unique requests for consults, just shy of one new request per day!
Feedback from inpatient staff has been overwhelmingly positive with the consultation and support ensuring patients’ medical and mental health and/or addictions needs are being met during inpatient stays.
Page 17 of 21
Since our last newsletter, the EMHAS Patient and Staff Satisfaction Survey has continued to generate numerous responses. Feedback from our patients and staff members provides valuable guidance for program operations and future development.
When a person comes to the Emergency Department experiencing a mental health or substance abuse crisis, they need immediate care delivered in a compassionate and timely manner. Their time in the Emergency Department is not long, but a critical outcome of their visit is to be connected to other service providers and having a plan of care when they leave the hospital. The patient satisfaction survey has revealed an increasing level of satisfaction with how well the EMHAS teams are doing in supporting these transitions of care for our patients.
Look below to see how we measured up on two measures of transition of care!
EMHAS PATIENT AND STAFF SATISFACTION SURVEY UPDATE
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19
Percent of adult patients indicating satisfaction with survey items related to transitions of care
I know who I will be seeing next
Knew next step in plan of care when left ED
Focus on supportedtransitions
We would like to thank the following contributors to the Fall/Winter 2018 EMHAS Newsletter: Nick Czuzdi, Tara Endeman,
Pam Kjertinge, Melanie Iancovich - Homewood Health Centre; Michelle Bott & Kate Pautler - Guelph General Hospital If you have comments or suggestions, please feel free to contact:
EMHAS Operations and Quality Committee Chair EMHAS Project Lead
Michelle Bott 519-837-6440 x2831 – [email protected] Kate Pautler 519-837-6440 x3693 – [email protected]
Page 18 of 21
REPORT OF THE CHIEF OF STAFF BOARD OF DIRECTORS OPEN MEETING
JANUARY 29, 2019
FOR INFORMATION MAC Highlights The Medical Advisory Committee met on December 3, 2018 and January 7, 2019. The MAC Highlights are attached for your information. J. Caspers Chief of Staff
Page 19 of 21
December 2018
Chief of Staff Dr. Jennifer Caspers
President & CEO Marianne Walker
VP Patient Services and CNE Eileen Bain
President of the MSA Dr. Steve Hoey
Director Quality and Professional
Practice Melissa Skinner
Department Presentation on
Quality Indicators: Midwifery &
OB/GYN – Carol Bennett and Dr.
Valerie Mueller
Professional Staff Recognition: Letters of recognition: Drs. Phil Harvey (GM) and Ken Reed (GS); Trillium Gift of Life to the entire hospital; Dr. Huss Kapasi (ED); Dr. Chris Steyn (Ortho – GRH).
Gifts of Gratitude: Dr. Darren Lin (ED)
Budget Update: Challenging forecast with a year end-deficit forecasted. The main contributing factor to this deficit is the additional unfunded beds which are expected to continue through the fiscal year.
Operational pressures: we continue to experience growth in in-patient activity compared to prior years. Overall, our patient days increased by 6% compared to October 2017 and are 16% higher than October 2016. For perspective, this means we have an average of 25 more patients in hospital each day than we did 2 years ago and 10 more patients than we did last year. This increase in patient days is largely driven by higher admissions from ED and an increase in ALC patients waiting for the correct placement to become available in the community.
The above pressures resulted in Medical Bed occupancy from 106% in October 2017 to 115% in October 2018.
Surge Planning: A draft multi-sector engagement plan for seasonal and general surge conditions at GGH and LHIN-wide was presented to the MAC by Dr. Digby and Melissa Skinner.
Healthy Hospital Survey for Professional Staff Final count for Professional Staff completing the survey= 67.2% - an improvement from our stellar results in 2016 of 62.4%. Raw comments and data have just been received from Metrics at Work.
Sub-Region Activity: LHIN-wide cardiac plan underway to be completed by 31 March, 2019.
Consent for the Administration of Blood Products: It is the responsibility of the MRP to obtain consent for the administration of any blood products. The wording on the consent – blanket for hospitalization or peri-operative - will be reviewed.
New Mentor Review Form: The revised form will be launched with the next incoming Professional Staff member.
Core and Special Privileges: These are being reviewed for consistency across departments.
Professional Staff Achievement Review (PAR): 52 of 99 completed to date – the reviewer shall make note of changes in privileges being asked for by members.
Recent Messages from the new Registrar of the College of Physicians and Surgeons (CPSO): 1. CPSO is a regulator not an educator; 2. CPSO is adopting an Alternate Dispute Resolution to manage some complaints; 3. Utilizing a “Right Touch” philosophy – evaluate risk and apply appropriate pressure in response; 4. Majority of CPSO complaints are in respect to communication and professionalism; 5. New draft policies – Continuity of Care
Strategic Objectives for MAC 2018-2019: Opioid Plan for GGH - The Opioid Strategic Plan (April 2017) was adapted with minimal changes to be circulated to
all departments and integrated as a policy within Professional Staff Clinical Policies ALMOST COMPLETE
An education module that all PS must complete on line and linked to re-credentialing DONE An intranet site accessible from the GGH home page will be made available with opioid
resources DONE It was suggested that our General Surgery colleagues consider implementation of the UWO
protocol for use of Tylenol + NSAID post-op for lap cholecystectomy and open hernia repair with a Rx for only 10 narcotic pills to be filled with failure of the alternate protocol and expiring within one week of surgery.
Page 20 of 21
January 2019
Chief of Staff Dr. Jennifer Caspers
President & CEO Marianne Walker
VP Patient Services and CNE Eileen Bain
President of the MSA Dr. Steve Hoey
Director Quality and Professional
Practice Melissa Skinner
Department Presentation on
Quality Indicators: Diagnostic Imaging
– Dr. Samir Patel
HAPPY 2019!
Professional Staff Recognition: Letters of recognition: ICU & Dr. Marcello Schmidt from Trillium Gift of Life Gift of Gratitude: Dr. Khaled Alshakman
Safety Issues: 1. From CIS: Do not write with blue pens – they cannot be scanned 2. From ACU: Smoke evacuation techniques must be used in ACU (as in OR) if using
cautery 3. From Pharmacy: In order to process medication orders correctly and efficiently,
under PS signature write name and always date and time your orders.
Influenza Alert: Increased number of influenza positive patients identified – Infection Control is watching cases closely and Housekeeping is increasing cleaning in some areas to help reduce the bio-burden. 5West has been declared in influenza outbreak.
Budget Update: Challenging forecast with a year end-deficit forecasted continues related unfunded beds.
Sub-Region Activity: LHIN-wide cardiac rehab plan underway to be completed by 31 March, 2019.
Healthy Hospital Survey for Professional Staff Final count for Professional Staff = 67.2%, increased participation since 2016. Received a general presentation by Organizational Development. Next steps: Each Chief will be briefed by the COS on the departmental results to share with their department.
Professional Staff Achievement Review (PAR): 64 of 99 (2018-19) completed to date – the reviewer shall make note of changes in privileges being asked for by members. Non-responders have been identified and advised that their reapplication may be contingent on completion of their PAR.
Strategic Objectives for MAC 2018-2019: Opioid Plan for GGH - The Opioid Strategic Plan (April 2017) was adapted with minimal changes to be
circulated to all departments and integrated as a policy within Professional Staff Clinical Policies DONE
An education module that all PS must complete on line and linked to re-credentialing DONE
An intranet site accessible from the GGH home page will be made available with opioid resources DONE
It was suggested that our General Surgery colleagues consider implementation of the UWO protocol for use of Tylenol + NSAID post-op for lap cholecystectomy and open hernia repair with a Rx for only 10 narcotic pills to be filled with failure of the alternate protocol and expiring within one week of surgery.
Page 21 of 21
